Austin, Texas is on the rise. It’s the 11th most populous city in America, and it’s one of the fastest growing metro areas in the country. Featured on virtually every top-10 list, Austin is known as a hub for high technology, education, government and being the live music capital of the world. The capital city is also home to the nationally respected Austin-Travis County EMS (ATCEMS) System. But there might be trouble in the capital of the Lone Star State. Local press reports from the past 24 months have raised concerns about the system’s performance and sustainability, and some stakeholders are calling for significant change. Is Austin’s EMS system in distress or broken?

Quick Assessment

According to the International City/County Management Association’s (ICMA) report EMS in Critical Condition: Meeting the Challenge, an EMS service is in distress if it meets any of the following six signs.1

1. Media or council investigations: The Austin-American Statesman and local media regularly report on issues with the Austin-Travis County EMS department, including stories on problems between Travis County and Austin about the interlocal EMS agreement funding and the results of City Auditor reports that are critical of the department’s safety and billing practices.2–4 The Austin Public Safety Commission has advised the Austin City Council to request a full department audit.5

2. Response time troubles: Fiscal year 2013 first-quarter performance reports to the ATCEMS Advisory Board show urban response time compliance for Priority 1 calls under 10 minutes at 91.24%; suburban compliance at less than 12 minutes was 75.09%.6

3. Internal issues: A November proposition resulted in voters approving an amendment of the city charter to grant uniformed, certified EMS employees collective bargaining rights, as well as stronger arbitration rights for hiring and firing disputes and the department’s commanders (field supervisors) sued the department over overtime pay.7,8

4. Turf battles: Tiffs between agencies have been minor, but media reports present relations between Austin-Travis County EMS and the County Emergency Services departments as stressed. Stakeholders’ proposals that the county pull out of the EMS system or that EMS be merged into the fire department are reported.9–11

5. Lack of accountability or transparency: County administrators have expressed concerns about performance outside the city and with reporting reliability.10 Limited performance data is publically accessible, but it’s not easily accessible and is reported only quarterly.

6. Financial distress: In 2012, the Austin-American Statesman reported the EMS department was to overrun its budget for the first time in 12 years by an estimated $910,000, and the City Auditor released a report on the department’s billing operations that identified several issues including not appropriately handling cash and other payments and failing to bill Medicaid for an estimated $150,000–$345,000.4,12

Given that ATCEMS meets all of the ICMA signs of distress, it’s easy to understand why Austin Public Safety Commission Vice Chair and Texas Monthly founder Michael Levy has described the system as “broken” and expressed concern about its leadership and sustainability.

The Method

Local stakeholder and media attention on the EMS system focuses on the pieces of the puzzle that frequently result in a negative assessment of the ATCEMS department. Still, these assessments haven’t taken a look at the macro level, and instead remain focused on individual processes or issues. Local stakeholders also haven’t attempted to apply reasonably accepted industry criteria to evaluate the current state of the system. This review attempts to follow a systematic assessment and present the findings in objective framework to understand the current state of the Austin-Travis County EMS system.

There are no universally accepted criteria for assessing EMS system quality. Most consultant reviews pull together evidence from firsthand experience and best practice from position papers, federal studies and consensus reports to develop a framework. This review mirrors that method and uses two primary sources: the American Ambulance Association (AAA) EMS Structured for Quality guide developed for communities to effectively contract for high-performance ambulance service and a paper published in the peer-reviewed journal Prehospital Emergency Care by physicians from the U.S. Metropolitan Municipalities EMS Medical Directors Consortium on evidenced-based performance measures.13,14

System Description

For the purpose of this report, ATCEMS is the main focus of analysis. Due to the climate in the EMS system at the time of research for this article, the author decided to focus on publicly accessible information. The majority of the information to follow was pulled from city and county documents, performance reports, and firsthand experience and knowledge of the EMS system. City and county elected officials and department leaders, labor representatives and oversight members also provided context and background about the state of the EMS system.

It’s acknowledged the 9-1-1 communications center and transport entity are only components of a complete EMS system, and success also depends on partners, such as medical first-response agencies and air medical providers. The following describes the full EMS system serving Austin and Travis County.

Medical first response is provided by a spectrum of organizations around the county, including corporate response groups, volunteer and combination fire districts, and the Austin Fire Department. MFR patient care is primarily delivered at the EMT-basic level.

ATCEMS is the exclusive provider of 9-1-1 ground response and transport in Travis County. ATCEMS is a municipal third-service agency within the city of Austin and is jointly funded by the city and the county. ATCEMS is an all-ALS system and primarily uses a fixed-station deployment model.

The EMS department was founded by city ordinance in 1976 as the exclusive provider of emergency and non-emergency ambulance service in the city. Prior to 1976, a private service had an exclusive franchise to provide ambulance services. In 1980, the non-emergency business was transferred to an exclusive private franchise provider.15

The Framework: Five Hallmarks

The AAA EMS Structured for Quality guide describes five hallmarks to ensure high-performance emergency ambulance service: 1) hold the emergency ambulance service accountable, 2) establish an independent oversight entity, 3) account for all service costs, 4) require system features that ensure economic efficiency, and 5) ensure long-term high-performance service. The following applies this framework to the Austin-Travis County EMS system.

Transport Accountability

Accountability includes monitoring clinical results and response time compliance, customer feedback, and evidence-based protocols. Austin is no different than most metropolitan EMS systems, and its performance accountability is reflective of most government EMS systems. Performance measurement occurs for several purposes and is reported in a number of venues. Measures aren’t publicly available in a single, easily accessible place.

Austin’s budget requires certain key performance indicators (KPIs) are measured and reports the data in a system known as the ePerformance Measures. The data is accessible publically—but not easily—from the city’s website. The measures are tied to the budget process and aren’t changed frequently. Measures aren’t updated in real-time and the reason why they aren’t isn’t clear.

Response times are an indicator for the Austin ePerformance Measures and for the Travis County interlocal agreement. Only the city compliance is reported in the ePerformance system, and there’s no publically reported county data. Reports to the ATCEMS Advisory Board include response-time compliance to an urban goal of 9 minutes 59 seconds and a suburban goal of 11 minutes 59 seconds. There appears to be no penalty for failure to achieve the response-time goal.

Out-of-hospital cardiac arrest survival has been a singular evidence-based measure since the 1980s. ATCEMS reports a 12.1% survival rate for the 2012 fiscal year in the Austin ePerformance system.16 Additional measures are internally tracked, consistent with the recommendations from “Evidence-Based Performance Measures for Emergency Medical Services Systems: A model for expanded EMS benchmarking.”14 ATCEMS Advisory Board minutes show time series charts of data on EMS call to door interval time for ST-segment elevated myocardial infarction (STEMI), cerebrovascular attack (CVA) and trauma. No industry standard performance goal exists, but each measure shows a mean of less than 40 minutes.

There’s no evidence that the EMS department surveys feedback from customers and reports the results. The EMS System's standards of care are developed through the Office of the Medical Director and are available online. Protocols appear to be evidence-based and reflective of industry standards and there’s no indication that medical equipment isn’t current.

Boards and commissions: ATCEMS falls under the authority of two oversight groups: the ATCEMS Board and the Austin Public Safety Commission.

The ATCEMS Advisory Board was originally defined by city ordinance and then further described in the EMS interlocal agreement between Travis County and the city of Austin. The Board’s aim is to monitor the performance of the whole system, not just the EMS department, and make recommendations to the city council and county commissioners related to EMS delivery. The Board receives performance reports from leaders in the EMS department, helicopter service and the Office of the Medical Director. Medical first response is not included.

The Board doesn’t have the authority to provide administrative control over any of the entities. Members are appointed by city council members and county commissioners, and include representation from consumer groups including neighborhood associations and two large hospital networks. The Board meets only quarterly, and its materials are accessible on the Austin website.

The Austin Public Safety Commission has a broader charge to provide budget and policy guidance to the Austin City Council related to the three public safety departments—EMS, fire and police—serving the city. It includes members from the community appointed by city council members. The Commission doesn’t receive standard reporting from the EMS department, and EMS agenda items are more topic-specific. The Board, which meets monthly, doesn’t have the authority to provide administrative control over any of the entities.

The Advisory Board and Public Safety Commission are external oversight bodies charged with reporting recommendations to elected officials. Neither has authority to direct the activities of any entity in the EMS system, and there’s no direct penalty for not acting on a recommendation or concern that has been raised. Absence of defined performance dashboard makes it difficult for the bodies to monitor performance reliability.

Accrediting bodies: The Austin-Travis County EMS medical communications center is accredited by the National Academies of Emergency Dispatch (NAED) as an Accredited Center of Excellence. It received initial accreditation in 2000 and was the first ACE center in Texas. Travis County’s STAR Flight. rescue helicopter program was accredited in 2000 by the Commission on Accreditation of Medical Transport Systems (CAMTS). ATCEMS was awarded accreditation by the Commission for the Accreditation of Ambulance Services (CAAS) in July.17 One of the two non-emergency franchise companies—Acadian Ambulance–Texas—is also accredited by CAAS.

Accreditation is a valuable process and provides standardized, industry recognized criteria and external evaluation. It ensures that an organization meets minimum standards for key structures and processes. The NAED’s accreditation includes confirmation of process reliability, but CAMTS and CAAS don’t assure performance reliability.

Physician medical oversight: Medical first response organizations and the ATCEMS 9-1-1 transport provider fall under the clinical oversight of the Office of the Medical Director. One of the EMS system associate medical directors is the medical director for STAR Flight. The private franchise providers have independent medical direction.

Accounting for All Service Costs

Often, EMS providers get squeamish when discussing the dollars and cents of their system. Public officials and citizens are often rather uninformed about EMS economics and whether their community is receiving a good value for their investment.

It can be difficult to quantify the true cost of operations for public entities because governmental accounting may not identify all of the actual costs of delivering service. This is especially true when departments benefit from shared services like public relations, legal, fleet or human resources. The numbers described below are sourced from publically accessible, self-reported data.

The ATCEMS budget is $56,058,891, which includes the communication center and the Office of the Medical Director, but not non-emergency transport.18 Based on the county’s current Census population estimate of 1.063 million, that’s a cost per capita of $52.68. A benchmark study in 2010 including 21 North American cities reported a median cost per capita of $42.43.19 The majority of the cities participating in the benchmark study deliver both emergency and non-emergency transport service. ATCEMS delivers only emergency transport service, meaning addition of the non-emergency transport costs would increase the cost per capita further. ATCEMS is also significantly subsidized through tax dollars; the department’s 2013 budget goal is to recover $18 million in user revenue, which is a third (32%) of the overall 2013 budget.

To put this in context, consider another Texas metro area—Ft. Worth. MedStar Mobile Healthcare covers a smaller geographic area (421 square miles vs. 1,022 square miles), but it serves a similar population and has a similar EMS incident volume. MedStar had a 2012–2013 budget of $33,118,507, which was funded almost completely through non-tax subsidy revenue.20 MedStar also achieves comparable clinical and operational outcomes.

Austin has been recognized as a heavily tax-funded EMS system for 30 years. EMS System Consultant Jack Stout once described Austin as an old Jaguar car he had a love/hate relationship with: “It was capable of combining superb performance with real luxury, but maintaining that performance required a high-capacity dollar injection system.”21 He also compared it on more than one occasion with high-performance EMS system models in Tulsa, Okla., and Kansas City, Mo., challenging that, with the ATCEMS budget, he could serve both the emergency and non-emergency transport volume and still pay every patient $50 back.22,23 Consultant Frank Heyman also noted the high cost of the EMS service in a 1985 benchmark report, but commented that “no one in the Austin area seems to think that is a significant factor.”15

Economic Efficiency

Several factors influence the economic efficiency of an EMS system, including covering multiple contiguous jurisdictions, providing emergency and non-emergency ambulance services, matching the supply of ambulance and caregivers to the predictable call demand, and having the right resources to do the job.

One element of efficiency comes from the economies of scale present in a larger service. Economies of scale are savings that can come from covering a larger region, which means more resources to provide coverage and response while sharing costs. ATCEMS is currently the exclusive provider of 9-1-1 ambulance service to Travis County. If the county, or one of the smaller cities, were to pull out of the system, economies of scale would be lessened for all parties.

Economies of scale can further be enhanced if the EMS organization provides both emergency and non-emergency services, further increasing the resources and diversifying the payer mix. ATCEMS doesn’t benefit in this case. Non-emergency ambulance service in Austin is provided through two companies—American Medical Response and Acadian Ambulance Service—that hold franchises with Austin, serving 42,572 responses (transports were not reported).24,25 The franchise process is unique because Austin is a closed system requiring city council approval for a provider to enter the market. Franchise providers then compete with minimal restriction or regulation. Franchise providers are required to be made available for disaster needs but aren’t called on to support or back up the 9-1-1 volume.

How a system deploys its resources and matches it to predictable call patterns can also significantly improve efficiency.26 ATCEMS primarily uses a fixed-station deployment model with some peak-load units. Ambulances perform move-ups as demand and coverage require, but it isn’t a dynamic deployment system. This limits the efficiencies of managing demand and reduces the flexibility to move resources. Lots of waste and crew fatigue is created by returning units to assigned stations vs. the next station requiring coverage.

Long-term High Performance

Sustainable high performance is described in “Hallmark 5” of EMS Structured for Quality as a service that includes a continuous improvement system that enhances performance without always requiring added cost.13 If the EMS system is unable to perform, then are mechanisms in place to use lateral benchmarking to confirm if the system remains a value and there’s a process to replace an unsuccessful provider?

ATCEMS has a business analysis and research function reporting to the EMS director and a traditional clinical quality improvement function in its professional practices and standards division.27 The Office of the Medical Director staffs a performance management and research coordinator.28 From published reporting, data is measured in such areas as response times, cardiac arrest, STEMI and stroke. Data is presented in a mix of aggregate summary statistics and time-series charting, but there doesn’t appear to be regular application of statistical process control. Quality is one of the department’s pillars; there’s no reference to an improvement methodology for enhancing process performance in use in the system.28

Similar to other communities with municipal EMS departments, there isn’t a process to routinely benchmark performance and confirm if the system remains a value to the community. The city doesn’t have a performance-based contract with its own department and, although the county has some performance expectations in the EMS Interlocal Agreement, they aren’t equivalent to the expectations in a traditional performance-based contract. There’s also no process to consider replacing the provider and doing so could be very disruptive.

Summary of the Hallmarks

Applying the AAA’s five hallmarks to ATCEMS reveals several quality factors are in place, and there are opportunities for improvement and development that may enhance the sustainability and results of the organization.

Limitations & Discussion

Use of the five hallmarks and evidence-based performance measures as a framework for evaluating an EMS system enables a high-level view and degree of objectivity. Stakeholders on the ground may struggle with this analysis because it doesn’t provide the whole story, nor does it provide analysis of organizational culture, workforce morale, operational process reliability, inter-agency relations or community relations. The overview does support answering the opening question of whether the EMS system is in distress (yes) or “broken” (no), but it does not evaluate every issue.

A contributing factor not discussed is the role of elected officials. In speaking with current elected officials for the county and city, there’s universal concern that the EMS system isn’t where they desire it to be. But there isn’t consensus on what’s wrong or how to repair it. Cost and reliability are common themes. This is made more complicated by conflicting lobbying from across the local EMS and fire community and ongoing press attention. Added to the noise is a pending Travis County judge election in November, which has included focus on EMS service in the county and proposals for system change.29,30

Local perception of ATCEMS’ national reputation is also a challenge. Local stakeholders believed the system was a national model or best practice of EMS service. The strong positive national reputation is true, but many are surprised that the system has also been used as a benchmark for high cost and low efficiency since its inception.

Two very real concerns include that 1) elected officials will feel the pull to act and will make significant change to the system without understanding what the community needs or what the system is capable of doing, affecting access, cost and quality, and 2) the continuing scrutiny and issues identified will erode confidence in the EMS department leadership forcing a change.

Conclusion

Using the ICMA six signs as a diagnostic, one could conclude the Austin-Travis County EMS system is in distress. The EMS system’s current performance, structure and funding do make it stable. Stakeholders may not be comfortable with the current outcomes, but the system is not “broken” and could be repaired. Doing so would require laser focus on shared outcomes, heavy emphasis on engagement and communication, and a collaborative action plan to change. The will and resources are present to achieve the aim if there’s community interest and strong leadership to do so. jems

David M. Williams, PhD, is the founder of TrueSimple Improvement (www.truesimple.com) and collaborates on Urban EMS System Design projects with Washko & Associates. He works in healthcare, education and ambulance service systems as an improvement advisor. He is on the faculty of the Institute for Healthcare Improvement and an alumnus of Leadership Austin. He serves on the board of a local federally qualified health center system and has lived and worked in Austin, Texas, for 15 years.

David M. Williams, PhD, is an improvement advisor at TrueSimple (www.truesimple.com), a quality improvement practice. He’s an improvement advisor for and on the faculty of the Institute for Healthcare Improvement. Contact Dr. Williams at 512/850-4119 or dave@truesimple.com.